Registered Nurse

Ivyhill is currently seeking to hire a Registered Nurse (Non-Practicing) to support its contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Regions’ premier coordinating authority for appointing and referral management services for beneficiaries in the Defense Health Network. 

Registered Nurse will have overall responsibility for timely review of Right of First Refusal (ROFR) requests, review of Specialty Care Referrals, sustaining up-to-date Specialty Clinic Referral Review tools and booking guidance, complying with Referral and Authorization Business rules, tracking, and resulting of referrals, and full use of Referral Management (RM) information management systems. Will conduct reviews for capacity, capability, medical necessary, deferral to network, and right of first refusal activities.

This is an onsite employment opportunity. 

Duties and Responsibilities

1. Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition per IRMAC guidelines. Stay abreast of facilities’ services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. Proactively collaborates with Managed Care Support Contract (MCSC), Product Line Leaders, RM, Appointing Center(s), other members of the healthcare team and MTF points of contact to address any process issues or concerns.
2. Review referrals within the established guidelines from a market approach utilizing MHS-GENESIS, MCSC Portal and other EHR's or databases when needed. Develop, maintain and update referral review tools as needed.
3. Understand the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care) and utilize deferral codes appropriately.
4. Elevate patients’ concerns, more complex clinical cases to Team Lead, Product Line leadership, or Referral Management (RM) leadership as appropriate.
5. Receive and initiate telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitor and process referral management MHS-GENESIS queues to ensure consults are being processed within the established guidelines.
6. Advise patients of their referral status to include providing references for benefit counseling assistance and/or patient advocacy.
7. Approval authority for all active duty and reserve/guard referrals under the supplemental health care program. Coordinate with Medical Director, Product Line leaders, and/or RM leadership for all active, reserve and guard referrals not covered under the TRICARE benefit for approval.
8. Review and maintain ROFR referrals into MHS-GENESIS and database within the established guidelines for proper processing in attempts to recapture workload from the network to the MTF.